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23 year old female patient with pain in the left upper abdomen. An ultrasound examination was requested to rule out renal stones.

Caption:Transverse image of the left upper abdomen

Description:There is fluid around the lowerpole of the spleen

Caption:Longitudinal image of the left upper abdomen

Description:There is fluid around the lowerpole of the spleen but not around the kidney

Caption:Transverse image of the pancreas.

Description:The tail of the pancreas is thickened and hypoechoic. There is a thin layer of fluid anterior of the pancreas.

Caption:Transverse image of the pancreas

Description:There is a hypoechoic area in the tail of the pancreas and there is a thin layer of fluid anterior of the pancreas

Caption:Transverse image of the pancreas

Description:There is a thin layer of fluid between the splenic vein and the pancreas and some fluid anterior of the pancreas

Caption:Longitudinal image of the pancreas

Description:A thin layer of fluid is seen anterior of the pancreas

Caption:Longitudinal image of the gallbladder

Description:There is a layer of tiny gallstones

Caption:Portal vein hepatic artery and common bile duct

Description:The extrahepatic bile ducts are not dilatated

Caption:Transverse image of the pancreas

Description:There is a hyperechoic structure in the distal common bile duct representing a tiny stone

Caption:Distal common bile duct

Description:There are two small (1-2 mm.) stones in the distal common bile duct.

Final Diagnosis

Acute biliary pancreatitis and cholelithiasis and cholecholithiasis

Discussion

The patient was referred for an ultrasound examination of the kidneys because the referring physician only wanted to rule out stones in the urinary tract. The fluid around the spleen however suggested other pathology. One of the causes of fluid in this area is a pancreatitis because the tail of the pancreas is in close relation to the spleen.

In an early stage of a pancreatitis the ultrasound findings can be very subtle. Ultrasound findings in pancreatitis include edema with swelling of the pancreas. Changes in echogenicty can be focal or diffuse. Peripancreatic changes include edema and fluid collections.

A CT scan is often the method of choice to examine the entire pancreatic and peripancreatic changes in patients with pancreatitis. There are however patients such as this patient where ultrasound can demonstrate these changes in pancreatitis. Also ultrasound is the method of choice to demonstrate the presence of gallstones in the biliary tract that can be a cause of a biliary pancreatitis. Especially small stones in a non dilatated common bile duct can be hard to detect. A careful examination of the papil area is necessary to avoid missing these stones.

Laboratory findings like Amylase and Lipase later confirmed the diagnosis pancreatitis

Follow Up

The patient responded well to the medical treatment and with an ERCP and papillotomy her common bile duct stones were removed. A cholecystectomy is already scheduled

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